Alternative Registration Form | Mulerider Kids College

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Mulerider Kids College

Student Information

Name*

First Last

Grade (entering into next year)*

Which MKC session(s) will the student attend?*

Afternoon camp

Age*

Date of Birth*

School Attended*

Race*

*Race and gender information are used for grant reporting purposes only.

Gender*

Did you receive a scholarship from Magnolia Public Schools?*

Yes

Are you applying for a SAU scholarship?

Yes

Please check all that apply to your family:*

Free School Lunch

Reduced School Lunch

SNAP Benefits

Medical Assistance

Other, please describe below.

Explanation and/or other information

Parent/Guardian Name*

First Last

Email*

Home Phone

Work Phone

Cell Phone

Mailing Address*

Street City State ZIP Code

Emergency Contact Information

Please list two people who can be contacted in the case of an emergency if parent/guardian cannot be reached.

Name*

First Last

Phone*

Name*

First Last

Phone*

Please list up to two people that will be responsible for picking up your child each day.

Name

Relationship

Allergy/Medical History

Does your child have any sensory sensitivities or preferences we should be aware of (noise, lights, textures, crowds, etc.)? Please describe anything that may help us support them.

Are there any known triggers that may cause your child stress or discomfort? What strategies help your child calm down or regulate?

Please list any known allergies or significant medical history.

Doctor

Name Phone Number

Medical Release

If I cannot be reached to make plans for emergency medical care for my child, I give my permission to SAU and its representatives to take my child to Magnolia Regional Medical Center.

• I give my permission to use photography, videotape, and/or audiotape in which my child may appear in SAU marketing and publicity.
• I understand that SAU is not responsible for any personal items (i.e. games, money, clothing) brought to the facilities. I understand that my child should not bring a cell phone, tablet, or any other electronic device to camp.
• I have discussed appropriate behavior with my child and am aware that inappropriate behavior will result in dismissal from the program without the benefit of refunded tuition.
• In the event my child suffers minor scrapes, bruises, or injuries I give permission for my child to be treated at University Health Services at SAU.

Waiver of liability

This release and waiver of liability executed this date by the undersigned, parent of __, is granted to Southern Arkansas University In consideration of the opportunity to participate in Kids College, that receipt of this benefit is hereby acknowledged, releasor voluntarily and knowingly executes this release and waiver of liability for any injury of the minor child resulting from participating in the activities of the SAU sponsored Kids College. This trip is a voluntary activity for the child.

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Waiver signature

Name*

First Last

Entering your name in the fields above will act as your electronic signature.

T-Shirts

T-shirt Size*

One t-shirt is included in tuition fee. Students must wear their shirts everyday!

Tuition

Tuition is $75 per camp, per student for the week. Registration is not complete until payment is received. Please use the separate payment link provided in the email with this form.

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Class Choices

For MKC - Your child will be enrolled in three classes per camp. For MTC - Your child will enroll in four classes, and one Service Project.

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MTC Wait List Choices*

Please select at least four different choices from below, including one service project.

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MKC Morning - 1st & 2nd Graders - Wait List Choices*

Please any classes below that your student may be interested in (at least three).

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MKC Morning - 3rd & 4th Graders - Wait List Choices*

Please any classes below that your student may be interested in (at least three).

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MKC Morning - 5th & 6th Graders - Wait List Choices*

Please any classes below that your student may be interested in (at least three).

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Afternoon classes

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MKC Afternoon - 1st & 2nd Graders - Wait List Choices*

Please any classes below that your student may be interested in (at least three).

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MKC Afternoon - 3rd & 4th Graders - Wait List Choices*

Please any classes below that your student may be interested in (at least three).

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MKC Afternoon - 5th & 6th Graders - Wait List Choices*

Please any classes below that your student may be interested in (at least three).

Coupon(s)

Code must be in ALL CAPS. You may enter and apply multiple coupons.

Final Schedules and detailed camp information will be EMAILED to all registrants after May 18th.

If you prefer to have your schedule mailed to you please let us know below.

DO NOT email - please mail a copy to me instead.

Email a copy of my child's schedule.

Please click submit just once and wait for the page to load. Repeated clicking could result in duplicate registrations and charges.

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Code

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Date

Mulerider Kids College

Mulerider Kids College

Student Information

Emergency Contact Information

Allergy/Medical History

Medical Release

Waiver of liability

Waiver signature

T-Shirts

Tuition

Class Choices

Afternoon classes

Schools & Colleges

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